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Framework for Discussion Who should be immobilized? How should they be immobilized? How can we Assure Quality?

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Who should be immobilized?

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Goal Clearing C-spine in the field?

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An 78 yo male brought in Code-3 by EMS after cardiac arrest. Dispatched for “possible heart attack”. Hx: Had been fishing that morning with son with no complaints. Stood up from recliner chair and collapsed onto ground. Case: 78 yo male

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Why immobilize? 253,000 people in US living with spinal cord injuries 12,000 new cases each year In US, cost of MVC related SCI estimated $34.8 billion per year 5 million patients in the US receive spinal immobilization each year ✤ Spinal Cord Injury Information Network (www.spinalcord.uab.edu)

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“It is estimated that 3 to 25% of spinal cord injuries occur after the initial traumatic insult”: During extrication During transit ✤ American Association of Neurological Surgeons, 2001 Why immobilize?

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Over the last 30 years there has been a dramatic improvement in the neurologic status of spinal cord injured patients arriving in the emergency department. 1970’s - 55% complete neurologic lesions 1980’s - 49% ✤ American Association of Neurological Surgeons, 2001 Why immobilize?

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“This has been attributed to the development of Emergency Medical Services initiated in 1971, and the pre- hospital care (including spinal immobilization) rendered by EMS personnel. What about NHTSA? ✤ American Association of Neurological Surgeons, 2001 Why immobilize?

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1999 NAEMSP Position Paper “There have been no reported cases of spinal cord injury developing during appropriate normal patient handling of trauma patients who did not have a cord injury incurred at the time of the trauma.” ✤

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1999 NAEMSP Position Paper “Although early emergency medical literature identified mis-handling of patients as a common cause of iatrogenic injury, these instances have not been identified anywhere in the peer-reviewed literature and probably represent anecdote rather than science.” ✤

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1999 NAEMSP Position Paper Spine immobilization is indicated with a significant mechanism of injury and at least one of following criteria: Altered mental status Evidence of intoxication A distracting painful injury (e.g. Long-bone extremity fracture) Neurologic deficit Spinal pain or tenderness

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1999 NAEMSP Position Paper Caveats: Language or communication barriers Extremes of age Difficult to assess intoxication in field Variable interpretation of spinal pain or tenderness ✤

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ATLS 2008 ✤ 2008 ATLS Course Manual, 8th edition 2008 ATLS Course Manual, 8th edition Several studies have shown correlation between the length of time on a rigid spine board and the development of pressure ulcers. “A paralyzed patient who is allowed to lie on a hard board for more than 2 hours is at high risk for serious decubitus ulcers.”

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Neutral Postion The “neutral position” is poorly defined: “The anatomic position of the head and torso that one assumes when standing and looking ahead” 12° of cervical spine extension on lateral radiograph ✤ American Association of Neurological Surgeons, 2001

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Neutral Postion “McSwain et al determined that more than 80% of adults require 1.3 cm to 5.1 cm of padding to achieve neutral positioning.” This appears to be a reference to PHTLS text ✤ American Association of Neurological Surgeons, 2001

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Quality Assurance

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1999 NAEMSP Position Paper “Currently, spinal immobilization is often performed based only on the mechanism of injury without consideration of the patient’s symptoms and physical findings.”

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1999 NAEMSP Position Paper “EMS systems adopting procedures for clearance from prehospital spinal immobilization must develop mechanisms for education and quality improvement to ensure safe and appropriate use of clearance protocols.”

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The median age of the fractures that were immobilized was 48 years The median age of the 7 fractures not immobilized was 82 years An age extreme criteria may enhance this guideline ✤ Myers, et al, Int J Emerg Med 2009; 2:13-17 Myers, et al, Int J Emerg Med 2009; 2:13-17

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Protocols for Immobilization

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Columbia Gorge Protocol SPINAL STABILIZATION Trauma patients with the following injuries or signs/symptoms should be treated with full spinal immobilization. Head or facial injury Decreased level of consciousness Head, neck or back pain, consider spinal stabilization. Any patient meeting the trauma system criteria The level of treatment given other patients will be left to the discretion of the senior EMT. The mechanism of injury should be considered in this decision. This protocol is not intended to discourage the use of full spinal immobilization on any patient. Consider padding the upper half of the board for patient comfort if time and circumstances permit.

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State of Jefferson Protocol SPINAL IMMOBILIZATION First Responder, EMT-B, EMT-I, EMT-P INDICATIONS : Patients with a risk of cervical, thoracic, or lumbar spine injury based on mechanism of injury and findings of spinal pain, tenderness or neurologic abnormality. PROCEDURE : For actual or suspected penetrating trauma of the spine, then spinal immobilization indicated For blunt trauma with mechanism for spinal cord injury, then spinal immobilization if any of the following are answered “yes”: